Somehow when a patient dies after an intense and emotional code, and you go back to the rest of the patients, their complaints about flank pain just don't seem to matter so much anymore.
I'm just saying.
I'm just saying.
Thursday, July 31, 2008
Calling the Code
There is always a big letdown when the Doctor looks around the room and says, "does anybody else have any ideas?" and you know that nobody does, and you don't either.
It is the way things go and I am okay with it - in fact, I think in many cases it would just be cruel and disrespectful to continue beating on a dead body, but somewhere deep down in the back of my mind, there is just a voice screaming, "NO! DON'T GIVE UP!"
Can you tell how my day went today?
It is the way things go and I am okay with it - in fact, I think in many cases it would just be cruel and disrespectful to continue beating on a dead body, but somewhere deep down in the back of my mind, there is just a voice screaming, "NO! DON'T GIVE UP!"
Can you tell how my day went today?
He Was Already Dead, Jim
Come to think of it, it is weird to read in the local news that a patient was "taken to ABC General Hospital where he died," when you know full well that he was dead long before he walked in the door. He was just declared dead at ABC General.
He's Dead, Jim
It is always weird to read about a death in the local news and then realize, "hey, I cut his pants off and started his second IV line."
Kind of brings a whole new angle to the story.
Kind of brings a whole new angle to the story.
Cruel Joke?
Why is it that the most critical piece of equipment that we use in the ER sounds exactly like a cheap video game?
Wednesday, July 30, 2008
One at a Time, Please
I hate having two rooms open. Yes, it is nice to be able to have a little breather, but it almost always means I am going to get two patients at the same time, and anyone who works in an ER can tell you that almost every patient encounter is extremely front-loaded. When a patient comes in, they are going to get a whole big pile of stuff dumped on them at the beginning of the visit: assessment by the doc, and assessment by the nurse, labs, IV start, EKG, radiology tests, registration, medications, and a whole host of other things. Then we enter the sit and wait phase, while the lab tests get done, the x-rays get read, the medications do their work, and the IV fluid infuses.
As the RN, I am very heavily involved in the initial phase - I'm doing an assessment, making sure the EKG is done and the urine is collected, starting the IV, giving the medications, etc. During the sit and wait phase, I'm mostly sitting and waiting with the patient. I generally like to do my own vital signs, but that is certainly a task that can be done by the Tech.
So if I have an open room, and my other patients are in the sit and wait phase, I have no problem receiving a new patient. In fact, it is nice, because I like to stay busy.
But when I get another patient and I'm still somewhere in the initial phase with a patient, then things get broken up. I don't want to leave the new patient just sitting and waiting to get all those things done, but I can't just leave my current patient to sit and rot, so I end up trying to bounce back and forth as much as I can, which, in the end, is slower, because each time I go into a room, I have to regain my bearings about just where we are.
Despite all that, this is part of life in the ER and one of the things you just have to get used to.
So all of what I just said was to set up this scenario from a while ago:
WARNING! RANT AHEAD!
I had just triaged an ambulance patient - 17 year old with arrythmia and atypical chest pain. I got in there and completed my secondary assessment. I tried to do it quickly because I knew we were getting full and I had another open room, and I didn't want to still be in the middle of the initial phase with this kid and then have to start at the same time with another patient. The assessment was slow going, because the kid didn't know much about medical history or meds or what was currently going on, or really anything, for that matter. I felt good, though, because nobody had popped thier head in the door to say that I was getting anybody in my other room.
Then I stepped out in the hall.
12 people were standing outside of my other room with IV trays and drug boxes and stethoscopes.
Someone had coded in the hospital and was brought to the ER and put in my room almost 15 minutes earlier, and for some reason nobody had bothered to tell me. So I went in the room (remember that I just finished the secondary in the other room and so I haven't even seen the chart yet, and my third room had a patient who had just gone to CT scan, and who I had just inherited from another nurse and knew very little about) and found that the charge nurse and the float nurse had the patient sedated and restrained and had given Ativan and had started two IV lines. That's nice. But nobody had charted anything, so I walk in and there are crying family members and chaplains and pharmacists and lab techs and ER techs all over the place, and the charge nurse looks up at me and says, "maybe you should get an ER record sheet and start writing down what is happening."
Okay. Maybe you should have someone pop their head in my room and let me know that I'm getting a coding patient. But I didn't say that. I don't like conflict.
The other two nurses helped me for a few more minutes and even put a foley in the poor lady and then left, with the float nurse asking me if I needed more help. Well, at the moment, I didn't need any more help with this patient, I just needed to get my hands around what the situation was and do a secondary and start paperwork for restraints and all the other little legal stuff that goes along with ventilated patients, so I asked her if she could keep an eye on my other two patients for a little bit, and mentioned that the doctor had said something about pain meds of the 17 year old before I had been sucked into this room.
Anyone who has worked with newly ventilated patients can tell you the struggle it is to keep up with all the paperwork and the legal requirements regarding restraints and sedation and vital sign monitoring. Add to that trying to balance the different sedating medications (Propofol, Ativan, Fentanyl, etc), IV fluids, ventilator settings, family sensitivities (a greatly overlooked skill in nursing), and GCS assessments, and you have an extremely time-consuming task.
But it's okay, because we are a team, and teams work together.
Right?
So finally I get a chance to get away for a minute after about an hour. I pop my head in the room next door and make sure the patient is alive and I ask Mom if other nurses have been in to help them. She says that yes a couple nurses came in, and so I am relieved, and head back in for round two on the vent patient. Nearly an hour later as I'm finally getting to a point where my paperwork is done and the patient is satisfactorily positioned and sedated (and it was a very hard battle because the Propofol was hung almost 20 minutes after the RSI, so we were constantly behind the curve). In walks another nurse with my 17 year old's chart. She pulls me aside (kind of) and says, "don't you realize that this is a yellow chart and there is nothing at all charted on here?"
So much for teams working together.
It turns out that someone went in that room to fix the Oxygen Sat monitor, but that was all that was done and nothing was charted. And although I felt betrayed and angry that nobody thought to watch my back while I dealt with the critical patient, the blame was technically on me because that patient was technically under my care. The charge nurse pulled me aside (kind of) and proceeded to tell me that I need to be sure to assess the patient every hour and chart it whenever I have a yellow chart. I bit my tongue again.
I asked the doctor about where the order was for the Toradol he had said he was going to give the patient, and he said, "I gave you a verbal order for that. Why should I have to write it down?" Well, Dr. E, because 1. verbal orders are not permitted in non-emergency situations, 2. because even when they are permitted, that is only when they can be writtn down by the nurse and read back to you and I didn't have the chart, 3. because you never said it as a verbal order, and 4. you didn't give any specifics (dose, route, frequency). And frankly, I don't think that "we'll give this patient some Toradol" qualifies as an appropriate verbal order.
So perhaps you can understand why I was frustrated and a little angry on top of the soreness and fatigue I was feeling from working as much as I have been lately.
You might even understand why I was not my usual sympathetic and empathetic self with the poor lady who came in with right flank pain and was squirming all over the bed and not holding still while I tried to get her vital signs (where was my tech, anyway?) and start an IV.
And hopefully you will understand my distress and remorse when I learned that it wasn't kidney stones, but rather a hemorrhaging Renal mass that required ALS transfer to a higher-level facility. Luckily for me, I was able to make it up to the patient and by the time the ambulance gurney wheeled out of the department, the patient held my hand and thanked me for my wonderful care (the best reward I ever get as a nurse).
Moral of the story: No matter how much things fall apart around you, in this game, you have to keep your cool.
As the RN, I am very heavily involved in the initial phase - I'm doing an assessment, making sure the EKG is done and the urine is collected, starting the IV, giving the medications, etc. During the sit and wait phase, I'm mostly sitting and waiting with the patient. I generally like to do my own vital signs, but that is certainly a task that can be done by the Tech.
So if I have an open room, and my other patients are in the sit and wait phase, I have no problem receiving a new patient. In fact, it is nice, because I like to stay busy.
But when I get another patient and I'm still somewhere in the initial phase with a patient, then things get broken up. I don't want to leave the new patient just sitting and waiting to get all those things done, but I can't just leave my current patient to sit and rot, so I end up trying to bounce back and forth as much as I can, which, in the end, is slower, because each time I go into a room, I have to regain my bearings about just where we are.Despite all that, this is part of life in the ER and one of the things you just have to get used to.
So all of what I just said was to set up this scenario from a while ago:
WARNING! RANT AHEAD!
I had just triaged an ambulance patient - 17 year old with arrythmia and atypical chest pain. I got in there and completed my secondary assessment. I tried to do it quickly because I knew we were getting full and I had another open room, and I didn't want to still be in the middle of the initial phase with this kid and then have to start at the same time with another patient. The assessment was slow going, because the kid didn't know much about medical history or meds or what was currently going on, or really anything, for that matter. I felt good, though, because nobody had popped thier head in the door to say that I was getting anybody in my other room.
Then I stepped out in the hall.
12 people were standing outside of my other room with IV trays and drug boxes and stethoscopes.
Someone had coded in the hospital and was brought to the ER and put in my room almost 15 minutes earlier, and for some reason nobody had bothered to tell me. So I went in the room (remember that I just finished the secondary in the other room and so I haven't even seen the chart yet, and my third room had a patient who had just gone to CT scan, and who I had just inherited from another nurse and knew very little about) and found that the charge nurse and the float nurse had the patient sedated and restrained and had given Ativan and had started two IV lines. That's nice. But nobody had charted anything, so I walk in and there are crying family members and chaplains and pharmacists and lab techs and ER techs all over the place, and the charge nurse looks up at me and says, "maybe you should get an ER record sheet and start writing down what is happening."
Okay. Maybe you should have someone pop their head in my room and let me know that I'm getting a coding patient. But I didn't say that. I don't like conflict.
The other two nurses helped me for a few more minutes and even put a foley in the poor lady and then left, with the float nurse asking me if I needed more help. Well, at the moment, I didn't need any more help with this patient, I just needed to get my hands around what the situation was and do a secondary and start paperwork for restraints and all the other little legal stuff that goes along with ventilated patients, so I asked her if she could keep an eye on my other two patients for a little bit, and mentioned that the doctor had said something about pain meds of the 17 year old before I had been sucked into this room.
Anyone who has worked with newly ventilated patients can tell you the struggle it is to keep up with all the paperwork and the legal requirements regarding restraints and sedation and vital sign monitoring. Add to that trying to balance the different sedating medications (Propofol, Ativan, Fentanyl, etc), IV fluids, ventilator settings, family sensitivities (a greatly overlooked skill in nursing), and GCS assessments, and you have an extremely time-consuming task.
But it's okay, because we are a team, and teams work together.
Right?
So finally I get a chance to get away for a minute after about an hour. I pop my head in the room next door and make sure the patient is alive and I ask Mom if other nurses have been in to help them. She says that yes a couple nurses came in, and so I am relieved, and head back in for round two on the vent patient. Nearly an hour later as I'm finally getting to a point where my paperwork is done and the patient is satisfactorily positioned and sedated (and it was a very hard battle because the Propofol was hung almost 20 minutes after the RSI, so we were constantly behind the curve). In walks another nurse with my 17 year old's chart. She pulls me aside (kind of) and says, "don't you realize that this is a yellow chart and there is nothing at all charted on here?"
So much for teams working together.
It turns out that someone went in that room to fix the Oxygen Sat monitor, but that was all that was done and nothing was charted. And although I felt betrayed and angry that nobody thought to watch my back while I dealt with the critical patient, the blame was technically on me because that patient was technically under my care. The charge nurse pulled me aside (kind of) and proceeded to tell me that I need to be sure to assess the patient every hour and chart it whenever I have a yellow chart. I bit my tongue again.
I asked the doctor about where the order was for the Toradol he had said he was going to give the patient, and he said, "I gave you a verbal order for that. Why should I have to write it down?" Well, Dr. E, because 1. verbal orders are not permitted in non-emergency situations, 2. because even when they are permitted, that is only when they can be writtn down by the nurse and read back to you and I didn't have the chart, 3. because you never said it as a verbal order, and 4. you didn't give any specifics (dose, route, frequency). And frankly, I don't think that "we'll give this patient some Toradol" qualifies as an appropriate verbal order.
So perhaps you can understand why I was frustrated and a little angry on top of the soreness and fatigue I was feeling from working as much as I have been lately.
You might even understand why I was not my usual sympathetic and empathetic self with the poor lady who came in with right flank pain and was squirming all over the bed and not holding still while I tried to get her vital signs (where was my tech, anyway?) and start an IV.
And hopefully you will understand my distress and remorse when I learned that it wasn't kidney stones, but rather a hemorrhaging Renal mass that required ALS transfer to a higher-level facility. Luckily for me, I was able to make it up to the patient and by the time the ambulance gurney wheeled out of the department, the patient held my hand and thanked me for my wonderful care (the best reward I ever get as a nurse).
Moral of the story: No matter how much things fall apart around you, in this game, you have to keep your cool.
Tuesday, July 29, 2008
Need Help Paying for Those Meds?
A website that I learned about a few years ago that you might want to learn about as well is the Partnership for Prescription Assistance.
At the time I was working in an allergy/pulmonology/sleep clinic and many of the medications that we prescribed regularly (Allegra, Advair, Provigil, etc) are expensive and do not have generics, so we gave out a lot of samples and filled out a lot of prior auths. One day somebody tole me about pparx and since then I have referred a lot of people to it. The website is a collaboration between a number of pharmaceutical companies and prescription assistance groups and acts as a resource to help you find ways to get your prescriptions for cheaper or even for free.
To test it out, I selected Prilosec, Synthroid, Atenolol, Klonopin, Xanax, Provigil, and Advair (a med or two from each patient I had today) and made up some basic information about myself (they don't ask for any identifying info, just stuff like what your salary is and if you have medicare). I made myself a relatively poor (1000 per month) medicare recipient in a 3 person household and they came back with 7 different programs to help cover my prescription meds. I glanced at the overviews for a couple of them and they seem like genuinely helpful legitimite programs (for instance, did you know that GSK offers a huge list of medications for free to needy families - such as Advair, Coreg, Avandia, Augmentin, Zofran, Flonase, Paxil, Requip, Wellbutrin, Imitrex and on and on and on?) Me neither. But now I do.
Anyway, for those of you that have a list of medications, and may be struggling to pay for them (or even if you aren't, it is worth seeing if there is any deal you can get), or for those of you who may have patients who struggle to pay for meds, go check this site out and put it on your list of helpful resources.
Do I sound like I'm getting paid for this? Maybe I should be.
Image borrowed using Google Image Search. I'll give it back. I promise.
Technorati Tags: pills, prescriptions, medicare, poor, medicine, drugs
At the time I was working in an allergy/pulmonology/sleep clinic and many of the medications that we prescribed regularly (Allegra, Advair, Provigil, etc) are expensive and do not have generics, so we gave out a lot of samples and filled out a lot of prior auths. One day somebody tole me about pparx and since then I have referred a lot of people to it. The website is a collaboration between a number of pharmaceutical companies and prescription assistance groups and acts as a resource to help you find ways to get your prescriptions for cheaper or even for free.
To test it out, I selected Prilosec, Synthroid, Atenolol, Klonopin, Xanax, Provigil, and Advair (a med or two from each patient I had today) and made up some basic information about myself (they don't ask for any identifying info, just stuff like what your salary is and if you have medicare). I made myself a relatively poor (1000 per month) medicare recipient in a 3 person household and they came back with 7 different programs to help cover my prescription meds. I glanced at the overviews for a couple of them and they seem like genuinely helpful legitimite programs (for instance, did you know that GSK offers a huge list of medications for free to needy families - such as Advair, Coreg, Avandia, Augmentin, Zofran, Flonase, Paxil, Requip, Wellbutrin, Imitrex and on and on and on?) Me neither. But now I do.
Anyway, for those of you that have a list of medications, and may be struggling to pay for them (or even if you aren't, it is worth seeing if there is any deal you can get), or for those of you who may have patients who struggle to pay for meds, go check this site out and put it on your list of helpful resources.
Do I sound like I'm getting paid for this? Maybe I should be.
Image borrowed using Google Image Search. I'll give it back. I promise.
Technorati Tags: pills, prescriptions, medicare, poor, medicine, drugs
Thursday, July 24, 2008
An Open Letter
To the young lady who we had to restrain:
Dear V,
Everybody has their moments. If you don't believe me, come find me when the voice on the other end of the phone comes on after I've been on hold for 45 minutes and tells me that "your call is important to us."
You had yours today.
I know it seems unfair that your friends made you come into the ER because they thought you were overdosing on benzos to kill yourself. You say that you weren't. I understand. I don't take sides in situations like this, but when we get that kind of allegation, we have to look into it. You weren't in a good mood, and understandably so. That is why I took a lot of time to help you understand where we were coming from with everything that we were doing. I told you that if you are straight up with us, then we'll be straight up with you.
Then you decided that you were going to leave. "It's my right," you said.
No. It isn't. We tried for 15 minutes to talk you down, to help you understand. During that time you tied up the doctor, myself, three techs, another nurse, four security guards, and eventually, five police officers. I told you that we didn't want it to become a struggle, and you scoffed. Trust me, though, we really didn't want it to become a scuffle. If we are in this business, it is because we care about people and want to be healers.
But there comes a point where we just have to do what we have to do, and if we have any doubt about you being suicidal, we have to keep you. Yes, you read that correctly. We HAVE to. No choice.
I'm sorry that you ended up getting thrown onto the bed. I'm sorry that the police were gruff and rude. I'm sorry that the restraints made you feel like a criminal. I'm sorry for how the whole thing went down. But I don't say I'm sorry to transfer blame onto myself, my coworkers, or the police. In fact, this whole thing rests entirely on your shoulders. All you had to do was stay with us for just a little bit. If you were "framed", then we would be able to get a pretty good idea of that and let you go. No problems, no questions.
What is really ironic, V, is that just a few minutes after that cop pulled out his taser gun, the urine results came back. No benzos. Just before you stood up and started pulling wires off, the social worker was literally walking across the ER toward your room to interview you. You would have been out the door in 30 minutes. Free to enjoy the rest of your night as you pleased.
Instead, we had to keep you for several hours while we waited for you to calm down and the Haldol to wear off.
I'm a nurse. It is my job to make sure that you stay safe and healthy, and I'm willing to do whatever it takes to do that, even if it means pages of notes and assessments every 15 minutes while I try to care for two other very sick people; even if it means standing there for 15 minutes to assure everyone's safety while you have that chat with your angry family member when I would rather be doing the 10 other tasks I have on my plate. I do it because I care.
See, what you may not understand now - or ever - is that everything I do is to help you have better outcomes. That is why I am a nurse.
So next time life throws you a curveball and you think the situation sucks, just roll with it. You are going to get through it, and we are there to help. So, in the words of the great philosopher Tom Cruise, "Help me help you."
Always there for you,
Braden
Dear V,
Everybody has their moments. If you don't believe me, come find me when the voice on the other end of the phone comes on after I've been on hold for 45 minutes and tells me that "your call is important to us."
You had yours today.
I know it seems unfair that your friends made you come into the ER because they thought you were overdosing on benzos to kill yourself. You say that you weren't. I understand. I don't take sides in situations like this, but when we get that kind of allegation, we have to look into it. You weren't in a good mood, and understandably so. That is why I took a lot of time to help you understand where we were coming from with everything that we were doing. I told you that if you are straight up with us, then we'll be straight up with you.
Then you decided that you were going to leave. "It's my right," you said.
No. It isn't. We tried for 15 minutes to talk you down, to help you understand. During that time you tied up the doctor, myself, three techs, another nurse, four security guards, and eventually, five police officers. I told you that we didn't want it to become a struggle, and you scoffed. Trust me, though, we really didn't want it to become a scuffle. If we are in this business, it is because we care about people and want to be healers.
But there comes a point where we just have to do what we have to do, and if we have any doubt about you being suicidal, we have to keep you. Yes, you read that correctly. We HAVE to. No choice.
I'm sorry that you ended up getting thrown onto the bed. I'm sorry that the police were gruff and rude. I'm sorry that the restraints made you feel like a criminal. I'm sorry for how the whole thing went down. But I don't say I'm sorry to transfer blame onto myself, my coworkers, or the police. In fact, this whole thing rests entirely on your shoulders. All you had to do was stay with us for just a little bit. If you were "framed", then we would be able to get a pretty good idea of that and let you go. No problems, no questions.
What is really ironic, V, is that just a few minutes after that cop pulled out his taser gun, the urine results came back. No benzos. Just before you stood up and started pulling wires off, the social worker was literally walking across the ER toward your room to interview you. You would have been out the door in 30 minutes. Free to enjoy the rest of your night as you pleased.
Instead, we had to keep you for several hours while we waited for you to calm down and the Haldol to wear off.
I'm a nurse. It is my job to make sure that you stay safe and healthy, and I'm willing to do whatever it takes to do that, even if it means pages of notes and assessments every 15 minutes while I try to care for two other very sick people; even if it means standing there for 15 minutes to assure everyone's safety while you have that chat with your angry family member when I would rather be doing the 10 other tasks I have on my plate. I do it because I care.
See, what you may not understand now - or ever - is that everything I do is to help you have better outcomes. That is why I am a nurse.
So next time life throws you a curveball and you think the situation sucks, just roll with it. You are going to get through it, and we are there to help. So, in the words of the great philosopher Tom Cruise, "Help me help you."
Always there for you,
Braden
So that's how you are reading my blog.
A couple weeks ago I asked how you were reading my blog and got 17 responses.
Thanks to everyone who stops by to take a peek into my world and for those who took the time to respond to this and other posts. Other bloggers know that getting comments are the highlight of our blogging day!
Oh, and the other day, my Google Reader total jumped from 18 to 34, so perhaps it only updates every few weeks.
And it seems like I remember someone asking in one of the comments somewhere about how I get my totals for Google Reader and for how many people are visiting my site.
For Google Reader, all you have to do is bring up any blog and at the top right part of the screen there is a link that says "show details". It will tell you how many posts per week the blog has (it says 0 for me...) and how many subscribers (which, now that I'm looking at it, has jumped to 39).
As for all the other details that I get (like when people from Wyoming come to visit), I use Google Analytics for that. To get Analytics working on my blog, all I had to do was copy and paste some code to my blog. Using blogger, I just added a page element at the bottom of the blog and put the code there. Within a day, I was starting to get numbers and it keeps track of stats for 30 days.
* No bloggers were paid in the making of this advertisement *
Thanks to everyone who stops by to take a peek into my world and for those who took the time to respond to this and other posts. Other bloggers know that getting comments are the highlight of our blogging day!Oh, and the other day, my Google Reader total jumped from 18 to 34, so perhaps it only updates every few weeks.
And it seems like I remember someone asking in one of the comments somewhere about how I get my totals for Google Reader and for how many people are visiting my site.
For Google Reader, all you have to do is bring up any blog and at the top right part of the screen there is a link that says "show details". It will tell you how many posts per week the blog has (it says 0 for me...) and how many subscribers (which, now that I'm looking at it, has jumped to 39).
As for all the other details that I get (like when people from Wyoming come to visit), I use Google Analytics for that. To get Analytics working on my blog, all I had to do was copy and paste some code to my blog. Using blogger, I just added a page element at the bottom of the blog and put the code there. Within a day, I was starting to get numbers and it keeps track of stats for 30 days.
* No bloggers were paid in the making of this advertisement *
Welcome, Wyoming!
I know that everyone will be thrilled to find out that finally, after all these years months weeks days, Wyoming has finally put itself on the map, thanks to a devoted reader from Casper.
Dear Mr or Mrs Casper,
Thank you so much for taking the time (2 minutes and 28 seconds, to be exact) to stop by my wonderful Wyoming-friendly website (www) and leaving your footprint on my world.
You may feel as though you are just one, and that in a sea of thousands, what does it mean, but let me assure you that although you represent just 0.03 percent of visitors to my blog over the past month, you represent at least 0.04 percent of my heart. Please, do come back again.
Sincerely,
Moi
Dear Mr or Mrs Casper,
Thank you so much for taking the time (2 minutes and 28 seconds, to be exact) to stop by my wonderful Wyoming-friendly website (www) and leaving your footprint on my world.
You may feel as though you are just one, and that in a sea of thousands, what does it mean, but let me assure you that although you represent just 0.03 percent of visitors to my blog over the past month, you represent at least 0.04 percent of my heart. Please, do come back again.
Sincerely,
Moi
Wednesday, July 23, 2008
Dilaudid
I just gave Dilaudid PO.
Seriously, like 20 minutes ago, right before I walked out the door, I went to help a nurse who was swamped and looked at what the doctor wrote: Dilaudid 2 mg PO.
I didn't know Dilaudid came PO. I went in to give it to the patient, and he said, "are you sure that's Dilaudid? I've never seen it in a pill before." Even my frequent fliers have never seen Dilaudid PO. I've only ever seen it in injectable forms. Is this a new thing or am I just ignorant to the ways of the Gods of the Council of Hydromorphoneus?
Seriously, like 20 minutes ago, right before I walked out the door, I went to help a nurse who was swamped and looked at what the doctor wrote: Dilaudid 2 mg PO.
I didn't know Dilaudid came PO. I went in to give it to the patient, and he said, "are you sure that's Dilaudid? I've never seen it in a pill before." Even my frequent fliers have never seen Dilaudid PO. I've only ever seen it in injectable forms. Is this a new thing or am I just ignorant to the ways of the Gods of the Council of Hydromorphoneus?
PIGI?
She had low abdomen/pelvic pain for 3 days and was experiencing headache symptoms. On my paper that I take into the room with me to keep my notes straight since my memory lasts approximately 15 seconds, I wrote:
PIGI
N/D
vag bleed
Okay, so I remember why I wrote the last two, but PIGI? What? I walked out to the nurse's station and got on the computer to put in the secondary, and stared at the paper for a couple minutes trying to figure out what I meant by PIGI. I still don't know.
I'm going senile in my old age.
PIGI
N/D
vag bleed
Okay, so I remember why I wrote the last two, but PIGI? What? I walked out to the nurse's station and got on the computer to put in the secondary, and stared at the paper for a couple minutes trying to figure out what I meant by PIGI. I still don't know.
I'm going senile in my old age.
Friday, July 18, 2008
It's What Ply?
You are going to have to trust me on this: I don't want to spend too much time talking about my booty; suffice it to say that I am somewhat of a fan. In fact, my booty is there for me all day long whenever I need it to provide wonderful padding for my seating needs.
As a reward, I splurge and get the nice toilet paper from Costco - not that Kirkland Signature stuff, but the
soft, quilted stuff that kind of feels like I'm stealing someone's old comforter when I use the bathroom. I believe it is approximately 187 ply.
I don't expect everyone to follow suit. My parents get the Kirkland Signature stuff, so when I go over there I know I will be using toilet paper that is about 1.25 ply. It aint the best, but I can live with it.
The hospital where I work, however, has found some magical means of developing a toilet paper that is actually a negative ply number. I keep watching the Discovery Channel in a vain hope of learning how it is possible to take sandpaper and whittle it down to it's basic neurons, converting it in the process to a completely transparent form that dissolves completely on contact with water or human skin. I'll keep you updated if I do discover this secret.
In the meantime, I never thought I would be jealous of the box of tissues we give to patients who have to use the commode chair.
As a reward, I splurge and get the nice toilet paper from Costco - not that Kirkland Signature stuff, but the
soft, quilted stuff that kind of feels like I'm stealing someone's old comforter when I use the bathroom. I believe it is approximately 187 ply.I don't expect everyone to follow suit. My parents get the Kirkland Signature stuff, so when I go over there I know I will be using toilet paper that is about 1.25 ply. It aint the best, but I can live with it.
The hospital where I work, however, has found some magical means of developing a toilet paper that is actually a negative ply number. I keep watching the Discovery Channel in a vain hope of learning how it is possible to take sandpaper and whittle it down to it's basic neurons, converting it in the process to a completely transparent form that dissolves completely on contact with water or human skin. I'll keep you updated if I do discover this secret.
In the meantime, I never thought I would be jealous of the box of tissues we give to patients who have to use the commode chair.
Wednesday, July 16, 2008
I Don't Need the Beamer, I'll Take the Hyundai
Me: Do you have any allergies to medications?
Patient: Percocet.
Me: That's an unfortunate medication to be allergic to.
Patient: No, it's great; it means I get Vicodin!
Patient: Percocet.
Me: That's an unfortunate medication to be allergic to.
Patient: No, it's great; it means I get Vicodin!
Tuesday, July 15, 2008
It Has Come to This: My Wife Left Me
I'm not sure if it was something I said, but this morning my wife took her stuff, took my 1 year old, and left.
She said something about "seeing other people", and mentioned parents and grandparents and siblings and cousins and barbeque chicken with mashed potatoes.
So we said our goodbyes and went our separate ways.
But it's okay. I know she'll be back one day (I have the Wii, after all).
In the meantime, I have scheduled myself to work two extra shifts a week for the next four weeks. Between now and when the family returns, I will work 207 hours, including approximately 10,000 hours of overtime. Wish me luck on that.
Speaking of Nashville Star (good segue, huh?), what is up with the people who keep voting for Coffey? The general talent on that show goes something like this: Gabe rocks, Melissa has got serious pipes, everybody else, including the judges really, really sucks. So why am I still watching? Because I'm trying to gain empathy for my patients who experience intense pain.
She said something about "seeing other people", and mentioned parents and grandparents and siblings and cousins and barbeque chicken with mashed potatoes.
So we said our goodbyes and went our separate ways.
But it's okay. I know she'll be back one day (I have the Wii, after all).
In the meantime, I have scheduled myself to work two extra shifts a week for the next four weeks. Between now and when the family returns, I will work 207 hours, including approximately 10,000 hours of overtime. Wish me luck on that.
Speaking of Nashville Star (good segue, huh?), what is up with the people who keep voting for Coffey? The general talent on that show goes something like this: Gabe rocks, Melissa has got serious pipes, everybody else, including the judges really, really sucks. So why am I still watching? Because I'm trying to gain empathy for my patients who experience intense pain.
Sunday, July 13, 2008
The Pain Scale
If you do not already know my opinion of the pain scale, please refer to my blog title.That said, pain needs to be treated. I've been in very severe pain before and I know it is terrible and not fun and makes everything hard to deal with. My wife has a relative who suffers from severe chronic pain, and it has taken huge chunks out of the quality of her life. But how do you treat it when it is so hard to quantify?
How can I take the 1 to 10 scale seriously when person a skips into the ER talking on his cell phone and drinking a Pepsi, all while complaining of 10 out of 10 pain, and person B is throwing up while blood gushes from a gaping wound and they are screaming in pain, only to tell me that it is at least a 5 out of 10?
And then you have the kids. We use the FLACC scale to try to determine pain in preschool children and the Wong-Baker faces scale in older children. Neither of these works any better. Seriously. I don't think I'm exaggerating to say that 90 percent of the kids that I show the faces scale to point to either the 0 (because it is smiling) or the 10 (because it is crying), and I used to work in a pediatric office, so I've done this thousands of times. FLACC has a place, but almost every kid that comes into the ER gets a 5 on the FLACC scale off the bat because it is a scary, uncomfortable place with lots of strange people walking in and out and trying to put stethoscopes all over the place on them.
I don't know the solution to this problem. I just try to do my best with every patient who comes in for some pain-related issue (85 percent of our patients). The only really useful thing that the pain scale does from what I can see is it helps to compare a patient to what they were an hour ago, but even then, I've had more times than I can count where I walk back in the room after having given a couple of dilaudid and the patient tells me, "oh I feel so much better now. Really a world of difference. Let's see, my pain was a 7 before; now it is probably a 6 or a 6.5." So now I have to chart that the pain went down one point. I'm just waiting for my day in court when the lawyer asks me why I didn't give the repeat dose of pain meds when their pain was still a 6.
Anyway, on to the point for which I was headed when I started this post: I've been sitting on a post from Ten out of Ten for a couple of months that I found interesting regarding a test to determine the severity of a patient's pain. A little whimsical, but it is a good reminder to pay attention to more than just what a patient says. (In fact, one of my favorite things to chart: stated pain out of proportion to physical presentation.) Then a few days ago, Scalpel posted about the Delta P. I was ready for an intelligent discussion of a new airline product, but was disappointed to just get a post about pain management, but at least it was an interesting post about pain management. The idea of his post is that if someone who normally has 6/10 pain presents with 10/10 pain, then they are not as urgent than someone who normally has 0/10 pain and comes in with 5/10 pain. Of course, this all hinges on their stated pain levels accurately reflecting what kind of pain they are in.
I don't think either approach would stand up in court (but your honor, she winced with the BP cuff and her Delta P was only 2), but they are useful in our individual assessments of how a patient is really doing, and may come in handy when we are trying to prioritize between three or four needy patients.
How do you deal with the broken pain scale system?
Saturday, July 12, 2008
Dr. Mario
One of the great video games ever made is the simple and fun Dr. Mario.
Now it has come out for the Wii as a downloadable add-on, which, of course, I instantly downloaded, remembering all the nights of fun competition my wife and I had enjoyed playing the original NES version.
Oh what fun!
But even more important, I learned a very important lesson on fighting disease that we should look into implementing in our healthcare system.
Dr. Mario first introduced us to the concept of determining what color a virus is and trying to find pills that are a similar color. Despite the logic of this approach, this has not, in fact, revolutionized the health care system.
But now the good Doctor is back with a new strategy: Get together six or eight doctors and run really fast into the crowd of viruses and just running in place really fast until you finally push them away.
I think it has great potential.
So to all you Docs out there, lets see if we can get together in groups and start running. It might work best if we put the patient at the end of a big treadmill. Any other thoughts on how we might implement this strategy?
You Know It'll Be a Good Day When...
Apparently not every day brings challenges in the ER. A few days ago was one of those days.
You know it is going to be good when...
* You come on shift and only two of your rooms have patients in them.
* One of those patients gets discharged before last shift's nurse leaves.
* The other is a drunk holdover from last night, but gets up on the first try and walks to the bathroom. Gone 30 minutes later.
* Your next patient is a wound recheck that involves approximately 3 minutes of your time.
* Your next patient's only complaint is nausea for 1.5 hours. That's right. No vomitting, no chest pain, no paresthesias, no back pain. Nothing. So IV, Zofran, labs to rule out heart probs, see you later.
* You get assigned an ambulance patient with chest pain... and find it has resolved by arrival to the ER. Yeah, he's there for a few hours waiting for a room to rule out MI, but your main job is to make sure vitals are charted every hour and the pain doesn't come back.
* You don't get any other patients for 4 hours.
* When you finally do get a patient, you are at lunch and so the IV is started, the medications are given, the labs are drawn, and all that is needed is a quick secondary exam.
* 5 minutes after you are done with the secondary exam, the patient is moved to another room because of a doctor switcharoo.
* You admit your chest pain patient and hove NOTHING AT ALL TO DO for the last hour and a half of your shift.
* You want to see if anyone needs help, but everyone else is seeing if anyone needs help as well.
* There are never more than 10 patients in the Main ER for the entire shift, and as few as 4.
* There is a surprise going away party for one of the nurses, so you don't even have to buy lunch (although it is sad to see a good charge nurse leave).
* Your day pretty much involved two IV starts, hanging three liters of fluid, giving Zofran twice, Nitroglycerin 3 times and putting on a Nitro patch. Oh, and getting vital signs. Oh, and a wound check (any pain? no. any discharge? no. redness? no. discomfort? no. Great, see ya)
Okay, so some people might not call that a good day, what with the boredom and all, but after the past couple of weeks, it was supremely nice to have a bit of a break.
That's the ER for you: sink or swim.
You know it is going to be good when...
* You come on shift and only two of your rooms have patients in them.
* One of those patients gets discharged before last shift's nurse leaves.
* The other is a drunk holdover from last night, but gets up on the first try and walks to the bathroom. Gone 30 minutes later.
* Your next patient is a wound recheck that involves approximately 3 minutes of your time.
* Your next patient's only complaint is nausea for 1.5 hours. That's right. No vomitting, no chest pain, no paresthesias, no back pain. Nothing. So IV, Zofran, labs to rule out heart probs, see you later.
* You get assigned an ambulance patient with chest pain... and find it has resolved by arrival to the ER. Yeah, he's there for a few hours waiting for a room to rule out MI, but your main job is to make sure vitals are charted every hour and the pain doesn't come back.
* You don't get any other patients for 4 hours.
* When you finally do get a patient, you are at lunch and so the IV is started, the medications are given, the labs are drawn, and all that is needed is a quick secondary exam.
* 5 minutes after you are done with the secondary exam, the patient is moved to another room because of a doctor switcharoo.
* You admit your chest pain patient and hove NOTHING AT ALL TO DO for the last hour and a half of your shift.
* You want to see if anyone needs help, but everyone else is seeing if anyone needs help as well.
* There are never more than 10 patients in the Main ER for the entire shift, and as few as 4.
* There is a surprise going away party for one of the nurses, so you don't even have to buy lunch (although it is sad to see a good charge nurse leave).
* Your day pretty much involved two IV starts, hanging three liters of fluid, giving Zofran twice, Nitroglycerin 3 times and putting on a Nitro patch. Oh, and getting vital signs. Oh, and a wound check (any pain? no. any discharge? no. redness? no. discomfort? no. Great, see ya)
Okay, so some people might not call that a good day, what with the boredom and all, but after the past couple of weeks, it was supremely nice to have a bit of a break.
That's the ER for you: sink or swim.
Crass-Polination Blog
I just want to say that my favorite ER Nurse blog to read is over at Nurse K's place.
Somehow she finds time to post something just about every day, and they are always interesting and insightful, and "If you're dying, she'll save you, if you're looking for narcs, she'll show you the door. Nurse K knows her stuff, and loves her work, and her blog shows why being an ER nurse is one of the best jobs around" (oops did I accidentally put that in quotations to make it easier for Nurse K to cut and paste it into her sidebar? And then did I conveniently provide her with a link to 20 out of 10? Sorry about that. My fingers must have slipped.)
Go check her out, but whiny entitled commies need not apply.
Somehow she finds time to post something just about every day, and they are always interesting and insightful, and "If you're dying, she'll save you, if you're looking for narcs, she'll show you the door. Nurse K knows her stuff, and loves her work, and her blog shows why being an ER nurse is one of the best jobs around" (oops did I accidentally put that in quotations to make it easier for Nurse K to cut and paste it into her sidebar? And then did I conveniently provide her with a link to 20 out of 10? Sorry about that. My fingers must have slipped.)
Go check her out, but whiny entitled commies need not apply.
Thursday, July 10, 2008
How Are You Reading My Blog?
There are 18 people who subscribe to my blog using Google Reader. Compared to the number of visits I get every day, that is an incredibly meager number... even moreso when you consider that at least 6 of those are directly attributable to my family members.
So besides those who just come here casually via a link from another nursing blog, how are the rest of you reading my posts?
So besides those who just come here casually via a link from another nursing blog, how are the rest of you reading my posts?
New Poll
I have a new poll in my sidebar. Take a moment and let me know how it is on your unit when it comes to anti-nausea medications. If you want to comment on the issue, do so here.
You Know It'll Be a Bad Day When...
Every day brings new challenges in the ER. Some more than others. A few weeks ago was one of those days.
You know it is going to be bad when...
* You come on shift to find the board full of nothing but yellow charts
* You are just walking out of triaging the chest pain patient who came in by ambulance, and without a chance to check on your dyspnea patient who just came back from MRI (for possible spinal cyst!?!?), you see the medics roll into your room with a 91 year old.
* You go in the room to deliver critical medications for your chest pain patient only to learn - as your saline flush explodes all over you - that the medic messed up the IV and didn't get it inserted properly... tack on 30 minutes of trying to save the site and eventually starting an IV on the opposite arm. Hope your other patients are all right!
* All three of your patients have admission orders... at the same time.
* One of your patients is getting out of bed to leave AMA, the other is threatening to do so in order to go smoke, and the third is more confused now than when she got there, but you don't have time to check it out.
* The Tech comes up to you and says, "I'm thinking of just putting a big ABD pad on that scalp lac and then wrap a bunch of tape around his head to keep it in place"... and she is serious.
* As you walk in the door to start your shift the 550 pound patient is checking in. You have an open room. Yeah.
* You look up on the tracking board and see more patients in the waiting room than there are in the ER.
* You take just "a minute" to help settle this ambulance patient for another nurse and find out that she has become completely unresponsive. Completely. As in no response from sternal rub or fingernail pressure or baseball bat to the temple. Nothing. How do you spell life flight to a Level 1?
* You are busy complaining about how difficult this day is and look up at the board only to realize that your load is no more difficult than anyone else's.
* Senior Management chose today to do a walk-through and start nit-picking about stupid stuff.
* Really, do they remember what it was like to work on the floor?
* Unit Manager was there, too, and had no choice but to go along with Senior Manager on the stupid stuff.
* Don't fire me.
* You finally get your lunch break - your first break of the day - 7 hours into your shift.
You know that you are in the right career when...
* Your day includes all of that for 10 hours, and as you walk out the door, you think to yourself, "well that was fun."
You know it is going to be bad when...
* You come on shift to find the board full of nothing but yellow charts
* You are just walking out of triaging the chest pain patient who came in by ambulance, and without a chance to check on your dyspnea patient who just came back from MRI (for possible spinal cyst!?!?), you see the medics roll into your room with a 91 year old.
* You go in the room to deliver critical medications for your chest pain patient only to learn - as your saline flush explodes all over you - that the medic messed up the IV and didn't get it inserted properly... tack on 30 minutes of trying to save the site and eventually starting an IV on the opposite arm. Hope your other patients are all right!
* All three of your patients have admission orders... at the same time.
* One of your patients is getting out of bed to leave AMA, the other is threatening to do so in order to go smoke, and the third is more confused now than when she got there, but you don't have time to check it out.
* The Tech comes up to you and says, "I'm thinking of just putting a big ABD pad on that scalp lac and then wrap a bunch of tape around his head to keep it in place"... and she is serious.
* As you walk in the door to start your shift the 550 pound patient is checking in. You have an open room. Yeah.
* You look up on the tracking board and see more patients in the waiting room than there are in the ER.
* You take just "a minute" to help settle this ambulance patient for another nurse and find out that she has become completely unresponsive. Completely. As in no response from sternal rub or fingernail pressure or baseball bat to the temple. Nothing. How do you spell life flight to a Level 1?
* You are busy complaining about how difficult this day is and look up at the board only to realize that your load is no more difficult than anyone else's.
* Senior Management chose today to do a walk-through and start nit-picking about stupid stuff.
* Really, do they remember what it was like to work on the floor?
* Unit Manager was there, too, and had no choice but to go along with Senior Manager on the stupid stuff.
* Don't fire me.
* You finally get your lunch break - your first break of the day - 7 hours into your shift.
You know that you are in the right career when...
* Your day includes all of that for 10 hours, and as you walk out the door, you think to yourself, "well that was fun."
Wednesday, July 9, 2008
Verbal Orders
From my above post about Doctors and Nurses, I got the comment from Vitum Medicinus asking:
Vitum, I have heard arguments for why verbal orders can be helpful, including such ideas as speed of medication delivery and eliminating handwriting problems, but as a whole verbal orders can be a dangerous thing.
First off, at least in my state in the US, a verbal order has to be written down by a nurse and then read back to the doctor and charted as such, so where a doc could just write "dilaudid 1 mg IV" a nurse would have to write "VORB dilaudid 1 mg IV by Dr. Peel/Braden, RN". So there goes the time-saving thing. Secondly, while there is the potential for me to mis-read a Doc's handwriting (and we have a couple Docs in my ER who I swear write with a pen stuck in their nose just to see if it can be done), there is equally the potential to mis-hear the Docs order as you are writing it. Also, a doc has to sign off on the verbal order at some point, and I have seen it happen where the doc remembers differently than what the nurse wrote down, or where the nurse didn't write anything down so that they could get the medication to the patient faster, and later the doc went in and wrote for different medications.
For my part, unless we are in a code situation (in which case there is a recorder), I hear what the doc has to say, flip the chart to the order page and hand it over. They scribble their note, and then I go get the med. It takes 15 extra seconds.
So in conclusion: If you go and write the order on the chart, then A. there is no need to remember what you ordered, B. There is no need to go back later and cosign it, and C. you know that at least the order was put on paper properly. It takes a few extra seconds, but it is a few extra seconds well-spent.
Of course that is all for the ER. On the floor it is a different story completely, as there are no Doctors hanging out on the floor and so it involves paging and telephone calls and faxes and whatnot, and that is one of the reasons I don't want to be a floor nurse.
I haven't been on the wards enough to know the rules, but wouldn't this
be in the best interests of the patient ie. so they can get their pain
meds faster??
Just asking, I admit ignorance...
Vitum, I have heard arguments for why verbal orders can be helpful, including such ideas as speed of medication delivery and eliminating handwriting problems, but as a whole verbal orders can be a dangerous thing.
First off, at least in my state in the US, a verbal order has to be written down by a nurse and then read back to the doctor and charted as such, so where a doc could just write "dilaudid 1 mg IV" a nurse would have to write "VORB dilaudid 1 mg IV by Dr. Peel/Braden, RN". So there goes the time-saving thing. Secondly, while there is the potential for me to mis-read a Doc's handwriting (and we have a couple Docs in my ER who I swear write with a pen stuck in their nose just to see if it can be done), there is equally the potential to mis-hear the Docs order as you are writing it. Also, a doc has to sign off on the verbal order at some point, and I have seen it happen where the doc remembers differently than what the nurse wrote down, or where the nurse didn't write anything down so that they could get the medication to the patient faster, and later the doc went in and wrote for different medications.
For my part, unless we are in a code situation (in which case there is a recorder), I hear what the doc has to say, flip the chart to the order page and hand it over. They scribble their note, and then I go get the med. It takes 15 extra seconds.
So in conclusion: If you go and write the order on the chart, then A. there is no need to remember what you ordered, B. There is no need to go back later and cosign it, and C. you know that at least the order was put on paper properly. It takes a few extra seconds, but it is a few extra seconds well-spent.
Of course that is all for the ER. On the floor it is a different story completely, as there are no Doctors hanging out on the floor and so it involves paging and telephone calls and faxes and whatnot, and that is one of the reasons I don't want to be a floor nurse.
Wyoming Update
A couple weeks ago, I put a call out for Wyoming peeps to show their faces. One commenter hinted that she might be from Wyoming, but if so, then Google doesn't think so. Wyoming still remains the only state not to send someone my way according to Google Analytics.
Some other things we learn from Analytics (WARNING: BORING STATISTICS AHEAD! TURN BACK NOW!):
* Montana and West Virginia are also pretty much slackers. Each state has only deemed my blog worthy of 1 visit.
* Besides my state (which isn't first), California, Texas, and Pennsylvania have visited most frequently. Do people actually live in Pennsylvania? I thought it was just a front for some Tom Hanks movie.
* Rhode Island and Vermont have only stopped by a handful of times, but when they come by, they stay to visit many pages per visit.
* People in Arkansas stay the longest (by a wide margin) when visiting my site. I'm not going to comment on why that may be.
* People in Mississippi stay an average of 5 seconds. Speed readers.
* I thought it was a joke at first, but Kannapolis really is a city, and it is 5th place, after "not set", my city (hope management isn't reading... I'm going to have to mind my manners), Seattle, and Los Angeles. Interestingly, Minneapolis is right after Kannapolis.
* I don't think I could live in a city called Kannapolis.
* I also don't think I could live in Cabot or Bradley, but they are next on the list.
* My Change of Shift post has attracted 10 times more people than the next-highest individual post, but only 1/3 of the total traffic to my blog.
* The next-highest totals are my posts on Alcohol and Calling Codes.
* The blogs who refer the most visits to me, in order, are Emergiblog, ERNursey, Madness, Nurse Ratched's Place, EDNurseasauras, Crass-Pollination, and Medscape Nursing, with several of the blogs that I linked to at Change of Shift coming in behind those.
* Still at the top of the heap for how people find me are from direct visits and Google referrals.
* 57% of visitors to my blog are using Internet Explorer (why?) and 34% use Firefox.
* Internet Explorer 7 was released in late 2006 and yet only 67% of my visitors have upgraded.
* One person is still using IE 4 (released in 1997).
* Almost 9 out of 10 visitors are using Windows. Next is Macintosh, followed by - are you ready? - IPhone.
* My wife and I also keep a family blog. In the last thirty days, it has had 1/10th the number of visitors as this blog. Of course, we don't advertise that blog and it is mostly family and friends that come by.
Interestingly, although visits to my blog have gone through the roof, the number of subscribers to my blog through Google Reader has not changed at all since the Change of Shift. This despite me touting Google Reader as the best invention since Charlize Theron.
Some other things we learn from Analytics (WARNING: BORING STATISTICS AHEAD! TURN BACK NOW!):
* Montana and West Virginia are also pretty much slackers. Each state has only deemed my blog worthy of 1 visit.
* Besides my state (which isn't first), California, Texas, and Pennsylvania have visited most frequently. Do people actually live in Pennsylvania? I thought it was just a front for some Tom Hanks movie.
* Rhode Island and Vermont have only stopped by a handful of times, but when they come by, they stay to visit many pages per visit.
* People in Arkansas stay the longest (by a wide margin) when visiting my site. I'm not going to comment on why that may be.
* People in Mississippi stay an average of 5 seconds. Speed readers.
* I thought it was a joke at first, but Kannapolis really is a city, and it is 5th place, after "not set", my city (hope management isn't reading... I'm going to have to mind my manners), Seattle, and Los Angeles. Interestingly, Minneapolis is right after Kannapolis.
* I don't think I could live in a city called Kannapolis.
* I also don't think I could live in Cabot or Bradley, but they are next on the list.
* My Change of Shift post has attracted 10 times more people than the next-highest individual post, but only 1/3 of the total traffic to my blog.
* The next-highest totals are my posts on Alcohol and Calling Codes.
* The blogs who refer the most visits to me, in order, are Emergiblog, ERNursey, Madness, Nurse Ratched's Place, EDNurseasauras, Crass-Pollination, and Medscape Nursing, with several of the blogs that I linked to at Change of Shift coming in behind those.
* Still at the top of the heap for how people find me are from direct visits and Google referrals.
* 57% of visitors to my blog are using Internet Explorer (why?) and 34% use Firefox.
* Internet Explorer 7 was released in late 2006 and yet only 67% of my visitors have upgraded.
* One person is still using IE 4 (released in 1997).
* Almost 9 out of 10 visitors are using Windows. Next is Macintosh, followed by - are you ready? - IPhone.
* My wife and I also keep a family blog. In the last thirty days, it has had 1/10th the number of visitors as this blog. Of course, we don't advertise that blog and it is mostly family and friends that come by.
Interestingly, although visits to my blog have gone through the roof, the number of subscribers to my blog through Google Reader has not changed at all since the Change of Shift. This despite me touting Google Reader as the best invention since Charlize Theron.
New Poll
I need a new poll for my sidebar, but I'm failing in the highest degree to come up with one. Any ideas?
Charting - President Bush Style
Today one of my coworkers gave me a lunch break and when I came back I found a note on a patient's chart saying that the patient had gone to "Speaking of getting words wrong, why can nobody in the entire world say Phenergan? Nobody I see seems to take that medication, though I've met a lot of patients who take Phenegren. In fact, even when the doctor prescribes it to go home with and I explain it to the patient and it is there right in front of them on the page in black and white, neatly printed from a laser printer, I still get questions like, "how long should I take the Phenegren for?"
I suppose it is that same mentality that results in me being called Brandon or Brady all the time.
And I can't leave a post about messing up words without mentioning the old holdout "jewelry", which is oh-so-frequently called "jewlery". I'm not sure what jewlery is, but I think it involves a funny little cap and a prayer book.
Update: I did a Google Image search for jewlery and came up with 163,000 pictures. Seriously. These are the people we get in the ER with random objects stuck up their noses.
Tuesday, July 8, 2008
Respect and Arrogance
Guitar Girl talks about an incident where she corrected an intern, and leaves the implication that the intern didn't take it too well. Madness has a different take on the story, and feels that it is silly for us to try to be careful of the doc's ego while they crush ours all the time. Go read those two posts before reading my take.
You back? Okay, here is what I think: two wrongs certainly don't make a right, and just because we sometimes get mistreated doesn't mean we have carte blanche to return the favor.
In the case of Guitar Girl's story, I don't see any reason why she needed to say anything in front of the patient. The danger to the patient wasn't imminent and because the facts were on her side, she would have had support from others outside the room. This is a situation where the only danger to the patient would have been if the nurse had gone and picked up the medication and administered it, so there was plenty of time to talk to the intern in the interim.
It would be a different story if she were in the room and the doctor had pulled up 60 of Toradol and was getting ready to push it, or in the middle of a code situation when you notice that something is being done incorrectly. In situations where the danger is immediate, then I think whoever notices the mistake has the responsibility to at the very least stop the action and pull the person away from the patient to explain, or if necessary, to say it right there and then; because you are right: safety trumps ego.
But here it is about more than ego for the doctor. Here we have a patient who is now doubting their treatment. If Ego gets undermined, who cares, but now we have credibility undermined, and a patient who doesn't think she is going to get the treatment she needs. Not only does this lead to lower satisfaction scores (who cares), but it leads to worse outcomes for patients. I'm a strong believer in the power of the mind over healing, and I have seen time and again that a patient who does not believe that they will get good care somehow doesn't get good care, regardless of what the caregivers actually do. Anything we can do to help a patient feel like they are getting the best possible care will improve outcomes, lead to better results, and improve patient satisfaction and Press Ganey scores.
So yes, there is absolutely no reason that doctors should arrogantly boss us around and make us look like fools, but there is also no reason that we should return the favor, unless we are saving our patients from immediate threat.
From the comments at Guitar Girl's post come two very good points: "Never go to a teaching hospital in July" and "Why is an intern giving a verbal order for a non-emergency med anyway?"
You back? Okay, here is what I think: two wrongs certainly don't make a right, and just because we sometimes get mistreated doesn't mean we have carte blanche to return the favor.
In the case of Guitar Girl's story, I don't see any reason why she needed to say anything in front of the patient. The danger to the patient wasn't imminent and because the facts were on her side, she would have had support from others outside the room. This is a situation where the only danger to the patient would have been if the nurse had gone and picked up the medication and administered it, so there was plenty of time to talk to the intern in the interim.
It would be a different story if she were in the room and the doctor had pulled up 60 of Toradol and was getting ready to push it, or in the middle of a code situation when you notice that something is being done incorrectly. In situations where the danger is immediate, then I think whoever notices the mistake has the responsibility to at the very least stop the action and pull the person away from the patient to explain, or if necessary, to say it right there and then; because you are right: safety trumps ego.
But here it is about more than ego for the doctor. Here we have a patient who is now doubting their treatment. If Ego gets undermined, who cares, but now we have credibility undermined, and a patient who doesn't think she is going to get the treatment she needs. Not only does this lead to lower satisfaction scores (who cares), but it leads to worse outcomes for patients. I'm a strong believer in the power of the mind over healing, and I have seen time and again that a patient who does not believe that they will get good care somehow doesn't get good care, regardless of what the caregivers actually do. Anything we can do to help a patient feel like they are getting the best possible care will improve outcomes, lead to better results, and improve patient satisfaction and Press Ganey scores.
So yes, there is absolutely no reason that doctors should arrogantly boss us around and make us look like fools, but there is also no reason that we should return the favor, unless we are saving our patients from immediate threat.
From the comments at Guitar Girl's post come two very good points: "Never go to a teaching hospital in July" and "Why is an intern giving a verbal order for a non-emergency med anyway?"
Saturday, July 5, 2008
Sweet Gig
I remember one nurse I used to work with who had a pretty sweet gig...
He worked Saturday and Sunday from 8 am until Midnight. The first 8 hours were standard pay and the second 8 hours were overtime pay. So in 2 days, he accumulated 40 hours worth of pay and had the rest of the week to himself.
Pretty sweet... if you can handle it. I'm not sure I could.
He worked Saturday and Sunday from 8 am until Midnight. The first 8 hours were standard pay and the second 8 hours were overtime pay. So in 2 days, he accumulated 40 hours worth of pay and had the rest of the week to himself.
Pretty sweet... if you can handle it. I'm not sure I could.
Thursday, July 3, 2008
ScribeFire
Yesterday I gave a plug for Google Reader, because it has made my blog-reading life easier. Now let me plug ScribeFire, which is a Firefox plug-in that has revolutionized my blog-writing life. No, I am not getting paid for this.
With ScribeFire, a simple post is just four amazingly easy steps: 1. When the inkling takes you to post something, just click the little orange notepad icon or press F8. 2. Give your post a title (remembering to capitalize all words or your brother gets mad). 3. Type stuff in to the body of the post. 4. Click the publish button.
But what if you want to have a little fancier post? Well, since ScribeFire pops up at the bottom of your screen, and the size is adjustable, you can still surf the web and look at websites while blogging. When you come to a page that you want to link to, follow these amazingly easy steps: 1. Make sure that the page you want to link to is visible in your browser. 2. Highlight the text you want to make into a link. 3. click on the link button. 4. ScribeFire automatically populates the URL box with the page you are currently looking at. Verify and click OK. Done.
Want to add an image? Click where you want the image, click the image button, and then either enter the URL for the image from the internet or find it on your computer. The image is imported and you can resize and relocate the image.
Want to add tags to the post? or Technorati links? You can do that, too. Want to be working on multiple posts at once? (right now this is one of six that I'm working on) not a problem. The posts are saved in "tabbed" format so that if you aren't quite done with it, but have another you want to work on, you make a new tab and come back to the old one later.
Changing fonts,
bolding or underlining words, correctingmisstaykes mistakes, changing font color,
all of this is not only possible but incredibly easy. Remember, I'm not getting paid for this, even though it sounds like it. I just love this little add-on so much that I can't help but get excited about it. It is the only reason that I was able to put together such a long and involved Change of Shift recently.
So if you are not using Firefox already, why not? And if you are, go to the add-ons page, and get ScribeFire. You'll be glad you did.
Can millions of people be wrong? (okay, so they can, but not with ScribeFire)
With ScribeFire, a simple post is just four amazingly easy steps: 1. When the inkling takes you to post something, just click the little orange notepad icon or press F8. 2. Give your post a title (remembering to capitalize all words or your brother gets mad). 3. Type stuff in to the body of the post. 4. Click the publish button.
But what if you want to have a little fancier post? Well, since ScribeFire pops up at the bottom of your screen, and the size is adjustable, you can still surf the web and look at websites while blogging. When you come to a page that you want to link to, follow these amazingly easy steps: 1. Make sure that the page you want to link to is visible in your browser. 2. Highlight the text you want to make into a link. 3. click on the link button. 4. ScribeFire automatically populates the URL box with the page you are currently looking at. Verify and click OK. Done.
Want to add an image? Click where you want the image, click the image button, and then either enter the URL for the image from the internet or find it on your computer. The image is imported and you can resize and relocate the image.
Want to add tags to the post? or Technorati links? You can do that, too. Want to be working on multiple posts at once? (right now this is one of six that I'm working on) not a problem. The posts are saved in "tabbed" format so that if you aren't quite done with it, but have another you want to work on, you make a new tab and come back to the old one later.
Changing fonts,
- making
- bulleted
- lists,
bolding or underlining words, correcting
adding long block quotes from another person or an article that you just read and having it separate from the rest of your text so that people can look at it and know that this is something that somebody else said and now you are going to comment on it or ridicule it or praise it,
all of this is not only possible but incredibly easy. Remember, I'm not getting paid for this, even though it sounds like it. I just love this little add-on so much that I can't help but get excited about it. It is the only reason that I was able to put together such a long and involved Change of Shift recently.
So if you are not using Firefox already, why not? And if you are, go to the add-ons page, and get ScribeFire. You'll be glad you did.
Can millions of people be wrong? (okay, so they can, but not with ScribeFire)
Not For Me
When I was in the job hunt I signed up to get automatic updates from a hospital in my city. Every once in a while I would get an email listing the new RN positions that were available. Fast-forward a half a year, and despite having a good steady job and no longer living in the same city as that hospital, laziness on my part has kept me receiving these updates.
Today, as if I needed it, I got one more reason that I will never work at a nursing home:
Posting Title: Registered Nurse (RN)
Shift: 1 - Day Shift
Department:
SKILLED NURSING CARE
Employment Status: Full-Time
Salary Minimum: 19.82
Salary Maximum: 28.70
External Description:
Long Term Care Nurse (RN) - $3000 Sign-on Bonus!
Yes, you read that correctly, they are hoping to attract "Skilled" Nurses, and to do so have been authorized to delve deep into their pocketbooks to offer a salary that is about 12000 dollars per year less than any other RN job in the state.
But fortunately, if I work long and hard and get years of experience, that rate will keep going up until it is competitive with starting RN positions at every other facility.
Granted, I would not do LTC even if the pay was better than other places - just not my thing - but really, less than 20 bucks an hour? No wonder Nurse K gets patients with unstable vital signs.
NurseExec? Can you help me understand this?
Today, as if I needed it, I got one more reason that I will never work at a nursing home:
Posting Title: Registered Nurse (RN)
Shift: 1 - Day Shift
Department:
SKILLED NURSING CARE
Employment Status: Full-Time
Salary Minimum: 19.82
Salary Maximum: 28.70
External Description:
Long Term Care Nurse (RN) - $3000 Sign-on Bonus!
Yes, you read that correctly, they are hoping to attract "Skilled" Nurses, and to do so have been authorized to delve deep into their pocketbooks to offer a salary that is about 12000 dollars per year less than any other RN job in the state.
But fortunately, if I work long and hard and get years of experience, that rate will keep going up until it is competitive with starting RN positions at every other facility.
Granted, I would not do LTC even if the pay was better than other places - just not my thing - but really, less than 20 bucks an hour? No wonder Nurse K gets patients with unstable vital signs.
NurseExec? Can you help me understand this?
Wednesday, July 2, 2008
Google Reader
While I still have people taking the time to come visit my blog, let me take just a minute and plug Google Reader. No, I'm not being paid by Google.
When I find a blog that is interesting enough that I want to see what else this person will have to say in a day or a week or a month, I subscribe to the feed using Google Reader. It is simple, intuitive, and extremely efficient. Not only that, but I don't need any additional software, and it works whether I am using Firefox (my main browser), Opera, or even if I am for whatever reason reduced to Internet Explorer. When I go to work and get on the computer in the break room, I can log in to my Google account and check my feeds if I want.
And I never miss anything that Nurse K or Kim or Scalpel have to say.
Go check it out. You'll be glad you did.
And for all you doubters out there: if my mother can do it, so can you. Hi, Mom.
When I find a blog that is interesting enough that I want to see what else this person will have to say in a day or a week or a month, I subscribe to the feed using Google Reader. It is simple, intuitive, and extremely efficient. Not only that, but I don't need any additional software, and it works whether I am using Firefox (my main browser), Opera, or even if I am for whatever reason reduced to Internet Explorer. When I go to work and get on the computer in the break room, I can log in to my Google account and check my feeds if I want.
And I never miss anything that Nurse K or Kim or Scalpel have to say.
Go check it out. You'll be glad you did.
And for all you doubters out there: if my mother can do it, so can you. Hi, Mom.
Monday, June 30, 2008
Wyoming, where are you?
Since the announcement three weeks ago that my site would be hosting the Change of Shift, the number of visitors nearly doubled overnight. Since posting the Change of Shift 4 days ago, the number of visitors has skyrocketed to a point that the number of daily visitors over this period is nearly 10 times the number of daily visitors 30 days ago.
I have had visitors from dozens of countries as disparate as Denmark and South Africa. Canadians have come out in force - from every province - to read what this USA dude has to say. I've had visits from London and Manchester and Edinburgh, and even Newcastle-upon-Tyne (yes, you.)
New Zealand has even sent me some traffic (how cool would it be to live in a city called Dunedin?).
And 56 of the 57 United States have stopped by, but Wyoming remains completely uninterested.
Why, Wyoming, Why? Did I offend you in some way? Do you just not need nurses in your state? Was it because I didn't show enough respect for your Geysers when I toured Yellowstone? Is it because you are too busy admiring Fossil Butte National Monument?
I love Wyoming. I'm an Ansel Adams fan. Really, I have a calendar and everything. The Beaches of Cheyenne is one of my favorite Garth songs. I really liked the movie Casper when it came out (but mostly because I thought Christina Ricci was cute). Yes, you don't have any major sports teams, and your minor league baseball team is the Casper Ghosts, but your state dinosaur is the Triceratops - and you don't mess with a Triceratops (unless it is really sick and then you have to look through it's droppings to see what is wrong, but I work in an ER and I do that kind of stuff all the time. well, okay, not with a Triceratops because they don't really check in that often, but with other patients who may also have lived during the Cretaceous period) And I love your state motto: "Equal Rights" (a little odd, perhaps, given that Wyoming is nothing but 50 year old white men... or at least that's what I've heard).
So come on, Wyoming. I've been a friend to you. Why can't you return the favor and be a friend to me, too?
Technorati Tags: Wyoming, Jurassic Park, Nursing, Blog Visitors, minor-league baseball
I have had visitors from dozens of countries as disparate as Denmark and South Africa. Canadians have come out in force - from every province - to read what this USA dude has to say. I've had visits from London and Manchester and Edinburgh, and even Newcastle-upon-Tyne (yes, you.)
New Zealand has even sent me some traffic (how cool would it be to live in a city called Dunedin?).
And 56 of the 57 United States have stopped by, but Wyoming remains completely uninterested.
Why, Wyoming, Why? Did I offend you in some way? Do you just not need nurses in your state? Was it because I didn't show enough respect for your Geysers when I toured Yellowstone? Is it because you are too busy admiring Fossil Butte National Monument?
I love Wyoming. I'm an Ansel Adams fan. Really, I have a calendar and everything. The Beaches of Cheyenne is one of my favorite Garth songs. I really liked the movie Casper when it came out (but mostly because I thought Christina Ricci was cute). Yes, you don't have any major sports teams, and your minor league baseball team is the Casper Ghosts, but your state dinosaur is the Triceratops - and you don't mess with a Triceratops (unless it is really sick and then you have to look through it's droppings to see what is wrong, but I work in an ER and I do that kind of stuff all the time. well, okay, not with a Triceratops because they don't really check in that often, but with other patients who may also have lived during the Cretaceous period) And I love your state motto: "Equal Rights" (a little odd, perhaps, given that Wyoming is nothing but 50 year old white men... or at least that's what I've heard).
So come on, Wyoming. I've been a friend to you. Why can't you return the favor and be a friend to me, too?
Technorati Tags: Wyoming, Jurassic Park, Nursing, Blog Visitors, minor-league baseball
No I here
New to the blogosphere is No Cap Here, who tells her story of life in the ICU. Recently she put up a post about the stupidity of the little competitions she has seen in nursing school, and now in orientation (I'm glad I never had any of that), and the importance of team work.
It is interesting, so check it out.
But really, the reason I couldn't resist linking to it is because she has the title "There Is No I In Teamwork" and everytime I see that, I can't help but point out that there is also no U in teamwork.
I'm just saying.
It is interesting, so check it out.
But really, the reason I couldn't resist linking to it is because she has the title "There Is No I In Teamwork" and everytime I see that, I can't help but point out that there is also no U in teamwork.
I'm just saying.
Was It Something I Said?
So I host Change of Shift, and then within a few days The Angry Nurse, ERNursey, and Monkey Girl all go away.
Hey guys, next time I'll wear deodorant. Promise.
Hey guys, next time I'll wear deodorant. Promise.
Thursday, June 26, 2008
Change of Shift
Ladies and Gentlemen (and those not quite so sure which they are, and those too immature to be categorized as either, and any well-trained animals who have learned to surf the internet, and Jerry Springer, if you are reading this), welcome to the Change of Shift. I am honored to be hosting this week's celebration of the nursing blogosphere and thrilled that you could make it. So grab a seat (why were you standing, anyway?), settle in, and get ready to meet some of blogging's brightest.I have only been an RN since last year, and at that only in the ER, but before that time I worked in rehabilitation of developmentally disabled adult criminals, as a CNA in Long-Term Care, as a Med-Surg CNA, as an ER Tech, as a Staffing Coordinator of a large hospital, as an LPN in a very busy Allergy/Pulmonology/Sleep clinic, as an LPN in Family Practice, as an LPN in Pediatrics, and as an LPN in Urgent Care. I've been around the nursing block a few times and have seen what a wide wide world it is.
So I thought it appropriate that this week's Change of Shift should celebrate diversity, because nursing is certainly a field that has huge amounts of it. I'm not talking about black or white, conservative or liberal, gay or straight, Muslim or Catholic, funny or Braden, or any of those standards of diversity. I'm talking about the vast array of distinct careers that make up the profession of nursing. Most people have a fixed idea in mind when they say "Nurse" (just ask the Animaniacs) but they don't realize just how different a nurse in one area is from a nurse in another area. True, we all start from the same roots, and everybody's job description is filled with mumbo-jumbo about assessing, diagnosing, planning, intervening, and evaluating, but go ahead and look at what nurses say about their specific jobs and you may be surprised to learn how similar, yet different we all are.
I have assembled a crack team of Nurse-blogging sharpshooters* and told each of them essentially the same thing. That is to share with the world why their kind of nursing is unique and special and what makes them want to do that more than any other field of nursing. I asked each nurse to submit this post to their own blog either last night or this morning, so I am almost as much in the dark as you are about what they will say. Unfortunately, I could not get a blogger for every type of nursing I wanted, so we'll just have to use our imagination on some of these.
Without further ado, let's meet the contestants, in completely random order:Emergency Nurses - Of course I start with what is nearest and dearest to my heart. Did you really think I would be that random? From the outset of my Nursing career, I never wanted to do anything other than ER Nursing - even when the big push came to rename our unit in a manner as to suggest that we need sildenafil - and it is all I have done as an RN. To introduce you to life in the unpredictable lane is EDNurseasaurus, the self-proclaimed "world's oldest diploma nurse and BSN undergraduate." Go for a prehistoric walk on the wild side and learn what makes her an ER Survivor. Her description of ER Nursing resonates very much with me and in a few short paragraphs, she paints a perfect picture of what life is like in the Emergency Room.
On the other side of the water, my favorite impactEDnurse shares bits of wisdom and insight in his free e-book emergency nursing unscrewed.
Or for those who appreciate their humor a little on the dark and dry side, go check out anything on Nurse K's blog, such as her latest tongue-in-cheek social commentary on poverty and inappropriate use of the ER.
Critical Care Nurses - Tracey at Nighttimenursing has been through it all as a nurse in the ICU. In the unit, even more than the ER, you are the captain of your own ship, and when things start going south, there is you and the patient and not much else. Sometimes, even the most stable of patients can go downhill quickly, and just keeping them alive is a task that falls right into the nurse's lap. Tracey shares just such an experience and gives you a flavor of all a Critical Care Nurse goes through in moments like that, and what makes it all worth it.
For a more nuts-and-bolts perspective, Nurse Sean (hey Nurse Sean, where did you go?) shares a day in the life of a new ICU Nurse on his blog and lays out in excrutiating detail why I don't want to be an ICU Nurse.
ICU Nurse Kathy takes us back to the good old days when nurses would make a frequent practice of stripping with her post, To Strip, or Not? No, it isn't nearly as exciting as you might guess... in fact, it is actually quite technical and might make you wonder, "why are you giving free publicity to this travel agency by posting this?" To which, of course, I answer "so that I can make a joke about nurses stripping, of course. Oh, and because this gives some light into the technical world of ICU nursing and stuff."
School Nurses - Alison at Schoolnurse's weblog talks a little about the mindset that a school nurse needs to have, while Penny at My Son Has Diabetes just made the switch from Home Health Nurse to School Nurse. It doesn't appear to be primarily a nursing blog, but you can read a little bit about her feelings on the change and her initial thoughts on the new job.
Operating Room Nurses - If I didn't do ER, I would likely do OR. I had the chance as a Nursing Student to witness several surgeries, including a 4-way heart bypass, a brain surgery, a laparoscopic appendectomy and others. If it wasn't so darn hard on my feet, I would have been very interested in OR as my first priority. Of course, OR nurses do much more than just stand on their feet for a long time. To give you an idea of what life is like in their shoes, Unsinkable Molly Brown at Livin' Large has put up a post to tell you what is so special about being an Operating Room Nurse in I Choose OR Nursing, and be sure to click the link halfway through to her post about the OR personality.Flight Nurses - Ready to swoop in at the most critical times to take care of the most critical patients, flight nurses are an amazing breed. When a Flight Nurse is called to the scene of an accident or to take a patient to a higher-level facility, they know they are going into a war zone and have to be ready to accept a patient on the verge of death, and keep them stable with absolutely nobody around to back them up. Crzegirl at Crzegirl, Flight Nurse has a two-part series about what a flight nurse is, first in words, then in pictures.
Med/Surg Nurses - It is almost unfair to lump all of the Med/Surg Nurses together. After all, this title can be given to Neuro Nurses, Ortho Nurses, Oncology Nurses, Surgical Nurses, Renal Nurses, and more. Fortunately for all you readers who do not have an entire 12 hour night-shift to kill, I'm not fair. Besides, I didn't get anybody to write a post for me about
Med/Surg Nursing. I admire nurses who can do "floor" Nursing. I can't. I did plenty of it in Nursing School, and before that I was a CNA on the floor. For one thing, I can't fathom not being able to walk up to the Doc and ask a question. Using a telephone? It isn't my thing. Fortunately for me, it is for a lot of other Nurses. You can read about some experiences on Med/Surg by NewGradNurse at Call A Code.Also, Oncology Nurse Laura has a post about 1:1 patient care and how it harms productivity. I have to say that this hits home for me. I don't like getting mad at suicidal patients for taking away my ER Tech, but sometimes I do feel that way, and it makes me feel bad. So there are a lot of downsides to 1:1 nursing, but is there a solution that is feasible?
Nurse Practitioners - the Life-saving Nurse Practioner at The Nurse Practitioner's Place grants us a peek into a day in her life. It sounds like getting a Master's Degree in nursing is no escape from the hated paperwork. If you read over her blog and just can't get enough of her, go and check out her other website, NP's Place, full of her thoughts, information about Nurse Practitioners, a very disturbing and cool picture of a Nurse Practitioner who follows your mouse around the screen, and links to ARNP sites and blogs, as well as other great nursing blogs. Mine isn't there, but I'm sure it will be soon... ;-)
Speaking of Nurse Practitioners, Max E. Nurse over at It Shouldn't Happen in Health Care has some thoughts on what was really meant... both for the patients, and for the providers (I especially love the translation for "There should be a bed on the ward for you any moment"). I like his blog much more than that of his cousin, Mr. Pad.
Public Health Nurses - Most nurses work with one or maybe a few patients at a time and in a controlled environment. Public Health Nurses work with everybody, and most of the time their patients don't even know that they are being watched over. Such is Sheila from Ordinary World, who shares her thoughts with us about why Public Health Nursing is important and what drew her in that direction in her post, Pump and Circumstance. Thank you, Sheila, for serving so many every day.
Outpatient Clinic Nurses - Rae, an Oncology Nurse from the aptly named raecatherine wants to share her journey of discovering what kind of diversity Nursing has to offer. Follow her through her winding road, and learn why she is a Clinic Nurse, and even more why she loves Oncology in her post never say never and how I got there. Check it out to see her journey, check it out to see a cute pediatric nurse, check it out to get a new perspective on end-of-life care, but most of all, check her out to see today's best usage of the phrase "small poos". When you have read that, go and read her little warning about how we judge our patients, and how quickly the tables can be turned back on us.
Student Nurses - Being a nursing student is not really a profession - or at least if someone is a student nurse for long enough to call it a profession, it is probably not someone that I want treating me - but Student Nurses bring to the table a special energy and interest and vitality that all-too-often fades as we get into the "real world" of nursing. La Bellota at Nursing School Chronicles recently graduated and started looking for work. Not too long ago I was in her shoes (they were a bit snug on me, I must say), and I remember the joys and the heartaches and, of course, the odd timing of everything falling into place, and then falling all apart. Read her five-part tale (1 2 3 4 5) of NCLEX to hiring as a brand new grad. Honesty and integrity in nursing? Who would have thunk it? Now let's go one step further with Nursing Student loco lorenzo from the loco days of locolorenzo and his thoughts about the power of love. I think this is a specialty of nursing students... and perhaps something that we should seek for in our profession as actively as we seek after the alphabet soup that comes after our names.And while we are talking about Student Nurses, let us all give a big welcome to Nursing Student Kaitlyn, who just wrote her first post on the Learning to Fly blog, and after an apologetic beginning, she gets right into a beautiful discussion on what Nursing really means and how it has already changed her life.
Finally, to all you Student Nurses out there, please take a few minutes and head over to prn penguin's place to read her extremely well thought out and educational post on how to survive as a 1st year nursing student. Then read it again.
Administrative Nurses - Where would the nursing world be without managers? Perhaps it is best if you don't answer that question. Anyway, many nurses become Nurse Administrators and help to keep hospitals and clinics running smoothly. My brother was a manager of a busy inpatient surgical floor of his hospital. Of course, in an attempt to save money, the hospital made him work as Charge Nurse three days a week and Manager two days a week and there was no way to do everything a Manager needs to do in just two days, so he saw the light and now works at an ER 20 miles down the road from me. And working nights nets him the same salary he was getting as manager. Wait, do I digress? Perhaps that is because I was not able to find a blogger to represent Administration. One interesting blog that I found, however, was Paul Levy's. He is CEO of a large Eastern US hospital, and shows a remarkable amount of approachableness (made up word of the day) and transparency on his blog, Running a Hospital.
Travel Nursing - Do you remember that Army kid in school? The one who came in halfway through the year and then moved just before school ended? Yeah, that's like the Travel Nurse. They can be in any department, but like the sale at Macy's, they are for a limited time only. It is a fascinating lifestyle, and invariably makes the rest of us lesser-paid Nurses jealous, and I'm sorry to not have a blogger to introduce it to you. However, for those who are attracted to the magical aura of Traveldom, Christina from NursingDegree.net shares a huge list of resources for you.
Alternative Nursing Careers - Hueina Su is not only a nurse, she is also a Certified Empowerment Coach (yeah, I had to look it up, too). She submitted an article about the power of the mind, and how Nirvana is Only a Thought Away. Holistic/Alternative care is not necessarily my cup of tea (no pun intended), but there are plenty of people who find happiness and healing through it, so go see what she has to say. Besides, how can I say no to a CEC?
Everybody Else - The list of different types of nurses could go on and on, and so in the interest of time and lack of volunteers, I will recommend to you Mother Jones at Nurse Ratched's Place for psychiatric nursing, May at about a nurse for telemetry nursing, At Your Cervix for Labor and Delivery Nursing, and The Mayor of Crazytown at All That Matters To Me for Home Health Nursing.
Of course, no post about the diversity of Nursing careers would be complete without talking about some of the other healthcare professionals who surround us and make our jobs possible. In addition to our fellow Nurses, let us take some time to celebrate these fine men and women who work side-by-side with us, easing our troubles and coming to our rescue when needed:
Respiratory Therapists -You hear it all the time in the hospital: "Respiratory Therapy to room 704." Where do these angels with the vents come from and what were they doing before magically appearing at your bedside to help save your crumping patient? Keepbreathing at Respiratory Therapy 101 wants to help us nurses know just what it is that RT is all about. Not only does he do a masterful job explaining the ins and outs of his profession, but he does so while correctly using the word plethora. Bonus points. Go check out A Nurse's Guide to Respiratory Therapists.
Social Workers - Until I started working in the ER, the Social Workers were just this nebulous group of people that did stuff sometimes. I never really understood their role. Now that I have interactions with them every day as I dump suicidal patients and drunks and battered wives on them, I have nothing but respect for what this stalwart group does. Hoping to help you understand a little bit, Still Dreaming, "a brand new social worker working with the lowest of the low" took the time to write a post especially for you at Awake and Dreaming about what it means to be a Social Worker. Go over to her place and get educated with I'm a What What Worker?
And don't forget that some Social Workers come in the Doctor variety. Therapydoc at Everyone Needs Therapy (ain't it the truth) wants you to know why Alice the waitress in room 7 has suddenly become Olga the conqueror.Medics - What? I included the ambulance drivers? That's like putting a picture of Manny Ramirez on a Yankees Blog! But wait... not so fast there, cowboy. Perhaps we can work some of our differences out. At least that is what Epijunky from Pink Warm and Dry hopes as she introduces you to the elephant in the room. You are right, Epi, we do have a lot in common. And thank you for that entertaining and insightful look into what EMS is all about. Any nurse who understands the life of a medic will have nothing but respect for them. And for another not-to-miss post from Epi's world, check out her tour of the inside of an ambulance. Humor and education all in one... who could ask for anything more?
Emergency Doctors - I didn't get anybody responding to my call for ER Docs, but please check out Scalpel or Sword or 10 out of 10 to get some insight into the mind and madness of those suture-wielding warriors we call Emergency Physicians.
Somewhat related, JC from Brain Blogger has a philosophical question as relates to Emergency Room Doctors. What do you do when a patient comes in who requires a specialty doctor, but you don't have one on call? How long can your patient wait for surgery?
Hospitalists - The Hospitalist is a fairly recent invention. Back when I was a kid, the PCPs admitted their own patients and then came around the hospital to see them before or after clinic hours or between tee times. This meant that a patient who needed to see the Doc at 0800, was granted immediate access to his or her doctor... at 1800. Fortunately, now we have Doctors who do nothing but help inpatients. The PCP or ER Doc decides to admit a patient and from that point, the Hospitalist takes over and does everything that is needed to help the patient and the Nurses achieve good outcomes. From all that I have seen and heard, this program works very well and results in shorter hospital stays and happier patients and Nurses. The Happy Hospitalist is an interesting and popular blog that chronicles the adventure of one such brave soul. Have fun.
Parent nurses - Sometimes, the most unwilling Nurses can be the most caring. Parent Nurses have no training in Nursing, and do not even choose the path they take, but for love and devotion to patients, nobody tops Mom and Dad. It is every parent's worst nightmare to have a child who suffers from chronic conditions, but it can also be one of life's biggest blessings. Hannah's Dad at Kintropy In Action writes about what it means to be a Parent Nurse and how it can change a life in Our Unexpected Nursing Career. After reading about their journey, go and feel the joy with the family when you read about finally giving up the ventilator.
And I'm not sure I can think of a better note to end on. Thank you for taking this journey with me through the amazing and inspired world of Nursing. One thing really stood out for me as we walked along the road of Nursing, and that is that nearly everybody who posted articles trying to explain why they do what they do said the same thing: I want to make a difference in people's lives.
And that, my friends, is truly what it is all about.
* Submitters were selected using a scientific method I call complete randomness. Generally I tried to find nurses who update their blogs regularly, who seem relatively articulate, who have a blog generally devoted to one specific kind of nursing, and as much as possible who do not receive a lot of traffic to their site (with a few notable exceptions). Endless thanks to all who took the time to help build the theme for this Change of Shift. If you feel snubbed or if I did not include your particular brand of nursing, please feel free to write a similar post on your blog and link to it from the comments.
Pictures found using image search on Flickr. If I'm using your picture and you don't like it, please accept my apologies and let me know and I will take it down. Final picture borrowed from Careways Trust.
Technorati Tags: Nursing, Change of Shift, Links, Nursing careers, ER Nursing, Nurses care
Tuesday, June 24, 2008
Voluntary Divert
So we just had the busiest day I've ever seen. I was working second triage and we were slammed with an endless parade of chest pains, possible AAAs, and severe hypotension patients, all salted with the usual complaints. I had to triage one pretty convincing varicella case in the quiet room. Hope those vaccines work. Top that off with ambulance traffic that would rival the traffic to K-Mart on any average day, and we were really cooking. Hallway beds were everywhere you looked, and we were occasionally putting pretty serious patients in the hall.
Needless to say, everyone's nerves were just a little on edge.
As I walked by one of the fast track PAs, I said, "make it stop!"
"Easy," he replied. "Get a paper and a marker and make a sign to put on the front door: FREE BEER AND PEANUTS AT SAINT CARINGANDSHARING GENERAL.* That should clear everybody out pretty quickly."
If only...
* Name changed to protect the innocent
Technorati Tags: triage, divert, humor, busy hospital
Needless to say, everyone's nerves were just a little on edge.
As I walked by one of the fast track PAs, I said, "make it stop!""Easy," he replied. "Get a paper and a marker and make a sign to put on the front door: FREE BEER AND PEANUTS AT SAINT CARINGANDSHARING GENERAL.* That should clear everybody out pretty quickly."
If only...
* Name changed to protect the innocent
Technorati Tags: triage, divert, humor, busy hospital
Monday, June 23, 2008
Chantix and Side Effects
There has been a bit of a back and forth lately between Nurse K and Mother Jones about a study involving using Chantix on PTSD patients. I don't know much about the actual study, and I'm far too busy (read: playing too much Mario Kart Wii) to read up on it properly, but I can't resist throwing my two cents in this ring where it concerns Chantix and its side effects.I was working at a pulmonology clinic when Chantix came out and sat in on several presentations from the drug reps about it (always take the drug rep lunches with a grain of salt). Since that time I have worked in a HMO clinic and Urgent Care Center and now in the ER. In all that time I have seen dozens and maybe even hundreds of people taking Chantix. For a few, it didn't work. For the other 90 percent, it worked like a miracle.
Number of people I have seen who have complained of serious side effects: 0.
Granted this is a very unscientific survey, and I've read the stories about the side effects and the chance of very real problems.
But if we are going to pull yet another miracle drug from the market or over-regulate it, while a 16 year old can buy alcohol from the corner market with a fake ID, and have even worse side effects occurring much more commonly (how often do we see psychotic and/or suicidal patients in the ER after pulling a few swigs off the old keg?), then I'll know we have gone completely and hypocritically bonkers.
And by the way, peeps, it's ChantIX, not ChantRIX, which every patient alive seems to say (kind of like Atenonol)
Image borrowed from peoplespharmacy.com. Found via Google Image Search.
Technorati Tags: Chantix, Smoking, Nursing, Quit Smoking, Miracle Drugs, Alcohol, Side Effects
Sunday, June 22, 2008
Submissions for Change of Shift
Calling for submissions for this week's Change of Shift. Please e-mail them to me at either pererau at gmail or at braden at bkellis dt com
Also, for the theme this week, we will be looking at the diversity of nursing careers, and I have e-mailed a long list of bloggers asking to return my email to take part in this. Many I have heard back from and confirmed support from, but there are still many that I have not heard back from or who seem to not be receiving my return emails. I need help from nurses who work in the following fields:
Emergency Nurses
Critical Care Nurses
School Nurses
Home Health Nurses
Labor and Delivery Nurses
Med/Surg NurseS
Telemetry Nurses
Long-Term Care Nurses
Psychiatric Nurses
Surgery Nurses
Student Nurses
Administrative Nurses/Managers
Nurse Educators
Nurse Practitioners
Outpatient Clinic Nurses
Also I would love to hear from:
Emergency Doctors
Hospitalists
For all of these categories, I have sent e-mail messages out and have not heard back or have not received confirmation. I tried generally to pick lesser-known bloggers (though in some cases I took what I could find and asked some big names), but it is much more important to me to have a lot of participation rather than a particular person... and I can always use more than one perspective.
So if you are reading this and fit any of the above descriptions and want to help me out with the Change of Shift, please email me at the above addresses or leave a comment with your email address and I will get in touch with you.
If you know anyone who fits the above descriptions, send them the link for this post and have them contact me please.
Also, for the theme this week, we will be looking at the diversity of nursing careers, and I have e-mailed a long list of bloggers asking to return my email to take part in this. Many I have heard back from and confirmed support from, but there are still many that I have not heard back from or who seem to not be receiving my return emails. I need help from nurses who work in the following fields:
Emergency Nurses
Critical Care Nurses
School Nurses
Home Health Nurses
Labor and Delivery Nurses
Med/Surg NurseS
Telemetry Nurses
Long-Term Care Nurses
Psychiatric Nurses
Surgery Nurses
Student Nurses
Administrative Nurses/Managers
Nurse Educators
Nurse Practitioners
Outpatient Clinic Nurses
Also I would love to hear from:
Emergency Doctors
Hospitalists
For all of these categories, I have sent e-mail messages out and have not heard back or have not received confirmation. I tried generally to pick lesser-known bloggers (though in some cases I took what I could find and asked some big names), but it is much more important to me to have a lot of participation rather than a particular person... and I can always use more than one perspective.
So if you are reading this and fit any of the above descriptions and want to help me out with the Change of Shift, please email me at the above addresses or leave a comment with your email address and I will get in touch with you.
If you know anyone who fits the above descriptions, send them the link for this post and have them contact me please.
Saturday, June 21, 2008
If You're Gonna Light a Fire...
So the flight nurses come in to transport the 80 year old C5 fracture to a level one facility. A couple minutes later, one of them runs up to the nurse's station and urgently says, "where's the narcan?"
So you can give two and a half of Valium to our already-drugged up patient, but you don't have Narcan? Tell your manager, that it tends to work better than the sternal rub you just tried.
Oh yeah, and try not to code our patients - at least not while they are in the ER. Thanks.
So you can give two and a half of Valium to our already-drugged up patient, but you don't have Narcan? Tell your manager, that it tends to work better than the sternal rub you just tried.
Oh yeah, and try not to code our patients - at least not while they are in the ER. Thanks.
Friday, June 20, 2008
Let's all say it together now...
FAST track.
Say it again: FFFAAASSSTTT Track.
So why does the charge nurse come up to me and say, "oh, by the way Braden we are going to put an acute onset chest pain in room 1. Don't worry, we'll get her to another room soon, I just need you to start an IV line and give some meds."
Dear, dear charge nurse: Have you ever given ACS meds before? I'm just asking, because there is nothing quick about giving initial ACS meds. So while I am busy doing that, the rest of fast track becomes stopped track.
Oh, and 6 hours later when I went home, the patient was still there. In fast track.
Say it again: FFFAAASSSTTT Track.
So why does the charge nurse come up to me and say, "oh, by the way Braden we are going to put an acute onset chest pain in room 1. Don't worry, we'll get her to another room soon, I just need you to start an IV line and give some meds."
Dear, dear charge nurse: Have you ever given ACS meds before? I'm just asking, because there is nothing quick about giving initial ACS meds. So while I am busy doing that, the rest of fast track becomes stopped track.
Oh, and 6 hours later when I went home, the patient was still there. In fast track.
Thursday, June 19, 2008
Spontaneous Pneumothorax
Young male comes in to the ER with complaint of sudden onset right sided chest pain while doing an activity at work that involved strenuous use of his right arm. He was in a lot of pain in his right upper chest and right shoulder which was worse with position changes and deep inspiration. Based on my secondary exam and the doc's review, it seemed like we were looking at a muscle pull. I told him there was a slight possibility that he had a collapsed young given his profile of being a young, tall, skinny male who smokes, but that really I was gearing up to go get the L&I paperwork for him as soon as he got back from x-ray.Needless to say, the chest tube tray is in a different location from the L&I paperwork. We knew it was a possibility, and had even warned him of such, but I would have thought the breath sounds would be absent on one side (granted they were certainly diminished, but I attributed that to smoking. My bad.
A couple hours later as we were getting to send him to med/surg, a young kid who was visiting him came up to me and asked in the most sober tone, "Can a short, skinny male get a collapsed lung, too?"
Image borrowed from C&S Solutions - cssolutions.biz via Google image search.
Tuesday, June 17, 2008
Fast What?
So I had the pleasure of working in fast track recently. Generally I enjoy fast track, because it is in and out and as the RN I can concentrate on one of the aspects of the job that I most love, which is patient education. The downside is the ridiculous amount of paperwork required given the speed with which patients come and go. In this 10 hour shift, we saw 26 patients, which may not seem so impressive until you take a moment to consider some of the patients that should never have been fast tracked (with the exception perhaps of the fish bone):* The 16 month old with a 102 fever of unknown origin. Fast track course: straight-cath (2 attempts needed), IV line (3 attempts and 3 nurses needed), abbreviated sepsis workup, APAP, Rocephin, etc...
* The 39 year old with back/flank pain and fever. Fast track course: IV line, 2 liters Normal Saline, Percocet, Dilaudid, Zofran, etc...
* The 21 year old with a sensation of "something stuck in my throat" after eating fish the night before. Fast track course: throat x-ray to confirm that there was, indeed, a fish bone stuck in her throat, several telephone calls and mountains of paperwork to arrange a transfer to a higher-level facility with ENT surgeons on call and to schedule an OR
* The 45 year old with elbow cellulitis here for IV antibiotics. Fast track course: after initial consultation/secondary exam, ER doc brought in to review the case, finally IV line and 90 minute infusion ordered
* The 5 year old with severe cellulitis of the thumb with streaking up to the elbow. Fast track course: IV line, pain medicine, skin marking, Rocephin injection, etc...
Combined ER time of those five patients: north of 16 hours.
Four IV starts are about what I expect in a regular ER assignment where the patients stay for an average of 3-5 hours instead of 45 minutes.
It was a day. All I can say is thank goodness for ER Techs.
As an aside: I went through my scribbled notes and as near as I can count, more than 10 of the 26 patients we saw were smokers. Compare that rate of 39% to the state-average of 18% smokers.
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